T.M. is a 57-year-old female with a several year history of recurrent swelling and pain with eating on the left side of her neck in the region of the left submandibular gland (SMG). She had previously seen an ENT who performed a CT scan which revealed several stones in the left proximal SMG duct near the gland. She underwent attempted trans-oral removal and apparently a part of the stone was able to be removed but the more proximal part was not. She had lingual nerve hypoesthesia (numbness) that lasted several months after the procedure and continued to be symptomatic with eating. We saw her in consultation a year after her initial surgery. On examination, the stone was palpable in the left posterior floor of mouth. We recommended sialendoscopy and probable trans-oral removal of the stone using a combined approach.Under general anesthesia, the sialendoscope was used to identify and verify the stone location. A mucosal incision was made along the left posterior floor of mouth and dissection carried down to the submandibular duct, which was identified easily using trans-illumination from the sialendoscope. The lingual nerve was also identified just below the duct. Once the stone was visualized through the duct wall, an incision was made in the wall and the stone easily removed. The mucosal incision was repaired. At the two-week follow-up appointment, she was eating without any symptoms and had no lingual nerve hypoesthesia.The so-called “combined” approach to salivary gland stones can be useful for large stones that cannot be removed using a sialendoscope and basket or laser lithotripsy. In theory, any stone could be managed using laser lithotripsy, but very large stones are both difficult to break up without damaging the duct wall and also are prohibitively time consuming. Submandibular stones that can be manually palpated can typically be removed trans-orally as in this case. The sialendoscope is helpful to trans-illuminate the duct and identify the exact location of the stone. For parotid stones, an external skin incision is required to use this approach.
D.S. is a 56-year-old man with a two-year history of intermittent swelling of the right neck who was referred by his primary care physician for evaluation. He related that the swelling was mostly associated with eating, and would begin as soon as he started to eat. The swelling was painful and usually lasted several hours. He had not found anything that relieved it other than just waiting for it to go downOn examination, he was noted to have a firm right submandibular gland (SMG), but was otherwise normal. A CT scan was performed with findings as seen in image (right). There is a stone in the right SMG that measures about 6x7 mm. The stone is at the junction of the SMG duct and the hilum of the gland.Because of his symptoms, it was recommended that he undergo sialendoscopy with attempted removal of the stone. We discussed that due to the relatively large size of the stone. it would likely be necessary to use the Holmium-Yag laser to break up the stone for removal, and if that was not possible, the gland should be removed. He wished to proceed. and he underwent successful sialendoscopy with laser lithotripsy as is seen in the video. At his one-month follow-up appointment, he was doing well with resolution of his symptoms.at can be manually palpated can typically be removed trans-orally as in this case. The sialendoscope is helpful to trans-illuminate the duct and identify the exact location of the stone. For parotid stones, an external skin incision is required to use this approach.
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